Full text of DOI:10.1089/107555303322284866

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 9, Number 4, 2003, pp. 571–576
© Mary Ann Liebert, Inc.
EDUCATION, INITIATIVES,
AND INFORMATION RESOURCES
Increasing Physician Awareness of the Common Uses
and Contraindications of Herbal Medicines: Utility of
a Case-Based Tutorial for Residents
CLAUDIA N. MIKAIL, M.D., M.P.H.,1 ELAINE HEARNEY, M.D.,2
and BARBARA NEMESURE, Ph.D.3
ABSTRACT
To determine the need for incorporating herbal medicine into residency curricula
Objectives:
and to assess efficacy of a case-based tutorial.
Pilot survey of residents’ knowledge, practice, and desire to learn about herbal reme-
Design:
dies indicated need for instruction. A case-based tutorial was given as a required conference for
residents. Participants were pretested, post-tested within 2 weeks, and their satisfaction evalu-
ated. The pretest, tutorial text, and post-test were distributed at clinic to residents who had
missed conference. The tutorial was also placed online.
Stony Brook University Hospital and Northport VA Medical Center, affili-
Settings/location:
ates of the State University of New York at Stony Brook, School of Medicine, Stony Brook, NY.
They serve a suburban/rural population.
Eight-two (82) residents were pretested (49 medicine, 7 preventive medicine, 12 fam-
Subjects:
ily medicine, 10 obstetrics-gynecology, and 4 anesthesia). Sixty-six (66) participated in the tuto-
rial. Residents in the pilot group ( 12) graduated before the tutorial was given. It was not of-
n 5
4). Because of scheduling, only 37 tutorial participants were
fered to anesthesia residents (
available for post-testing.
n 5
Tutorial on uses, contraindications, and drug interactions of popular herbal med-
Intervention:
icines was presented as a live session, text-only exercise, and online.
Pretest scores revealed a knowledge deficit, room for improvement in doctor-patient di-
Results:
alogue, and demand for instruction on herbal medicine. The mean knowledge score of all post-
tested participants ( 37) rose from 34% to 61% ( 0.0001). The live lecture group ( 29) in-
n 5
creased from 32% to 63% (
p ,
0.0001). The text-only group (
n 5
8) increased from 40% to 55% (
p 5
p ,
0.004). Satisfaction was high. Residents did not access the online tutorial, so it was not evaluated.
Residents request instruction on uses, contraindications, and drug interactions
n 5
Conclusions:
of herbal medicines and should ask patients about use more routinely. A live, cased-based tu-
torial appears effective for introducing herbal medicine into residency curricula.
1Division of Medical Genetics, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA.
2Department of Internal Medicine, Northport VA Medical Center/State University of New York at Stony Brook,
School of Medicine; Stony Brook, NY.
3Department of Preventive Medicine, State University of New York at Stony Brook School of Medicine, Stony Brook,
NY.
571

572
MIKAIL ET AL.
INTRODUCTION
Knowledge of basic herbal medicine con-
cepts was assessed using a combination of 14
multiple choice, true/false, and matching ques-
tions on the common uses, contraindications,
and potential drug interactions of herbal reme-
lthough some medical schools and resi-
dencies offer education in complementary
A
and alternative medicine (CAM), the propor-
tion specifically teaching herbal medicine re-
mains low. In 1999–2000, 66% of medical
schools offered coursework in CAM but only
35% included herbal medicine (Barzansky et
al., 2000).
dies such as
, ginseng, garlic, St.
Ginkgo biloba
John’s wort, saw palmetto, and echinacea. The
following are examples of questions asked:
For which of the following conditions is saw
palmetto most commonly used?
Educational approaches
a) Benign prostatic hyperplasia
b) Genital herpes
c) Neurogenic bladder
d) Renal calculi
Curricular innovations are necessary to fa-
miliarize residents with CAM concepts rele-
vant to medical practice, but the best methods
for achieving this are still being explored. For
example, the University of Washington, Seat-
tle, family medicine program teaches CAM
through lectures and evidence-based presenta-
tions by residents (Kemper et al., 1999). The in-
ternal medicine residency program at Rhode Is-
land Hospital/Brown University School of
Medicine (Providence, RI) incorporates CAM
into didactic and clinical experiences (Milan et
al., 1998). These interventions have been pop-
ular with residents, but alternate modalities
might be more appropriate for different train-
ing programs.
e) Urethral stricture
Which of these should not be taken with anti-
coagulants? (select all that apply)
a) Black cohosh
b) Chondroitin
c) Echinacea
d) Feverfew
e) Garlic
i)
j)
Glucosamine
Goldenseal
k) Kava kava
l)
m) Milk thistle
n) Saw palmetto
o) St. John’s wort
Ma huang
f) Ginger
g)
Ginkgo biloba
h) Ginseng
Questions about current practice included
how often residents asked patients about
herbal medicine use, how often they recom-
mended herbal remedies to patients, and how
frequently patients asked them about such
therapies. Desire to learn more about herbal
medicine was evaluated by a simple yes/no
question. Those responding, “yes,” were asked
to check off their preferred educational formats
(e.g., noon conference, evening/weekend sem-
inar, online, independent reading, case-by-case
with attending). Those responding, “no,” were
asked why.
Problem-based learning
A
small-group, problem-based learning
(PBL) approach appears appropriate for intro-
ducing herbal medicine into graduate medical
education (GME). This student-driven, active
learning method uses cases as catalysts for
learning, focusing on conditions that present
most typically and urgently in practice settings
(Barrows and Tamblyn, 1980).
MATERIALS AND METHODS
The pretest revealed a knowledge-deficit in
To assess the need for an educational inter-
vention, a small sample of graduating medicine
residents attending a required departmental
conference at Stony Brook University Hospital
(SBUH), Stony Brook, NY, were pretested on
knowledge, current practice, and desire to
learn about herbal medicine. Twelve (12) resi-
dents attended; all completed questionnaires.
basic herbal medicine concepts (mean 30%
5
standard deviation [SD] 9%), room for im-
5
provement in doctor–patient dialogue (only
17% regularly asked patients about herbal
medicine use), and inclination toward more ed-
ucation in herbal medicine (92% desired in-
struction, noon conference format preferred).
Consequently, a case-based tutorial address-

573
CASE-BASED TUTORIAL
ing pretest topics was developed for morn-
ing/noon conferences in internal medicine. The
author/leader of the tutorial was a preventive
medicine resident at SBUH who had studied
the frequency and nature of inquiries made
about herbal medicine to the Long Island Re-
gional Poison Control Center in New York, re-
vealing reasons patients took herbal medicine,
their concerns about safety, occasional adverse
tory which of the following remedies
would be most contraindicated?
a)
Aloe vera
b) Chamomile
c)
Ginkgo biloba
d) Glucosamine
e) Milk thistle
Participants took turns reading the scenario,
effects, and the need for physicians to be selecting answers, and reviewing summaries of
knowledgable about herbal medicine. remedies listed. The summaries were drawn
For evaluation purposes, the same pretest from multiple herbal medicine references (Fos-
was distributed to participants at the beginning ter and Tyler, 1999; Medical Economics Com-
of the conferences. Twenty-five (25) of 87 total pany, 1998; Miller and Murray, 1998; Ottariano,
internal medicine residents attended these con- 1999). The exercise stimulated animated dis-
ferences; 25 completed pretests. Because resi- cussion and enabled review of much material
dents rotate through different hospitals and in a short time.
have time off postcall, all were not available to
participate. There was no overlap with the pi- and charted on the board. Simple practice
lot group. guidelines were offered, such as always asking
After discussion, main points were reviewed
After pretesting, residents were given an in- patients about supplement use and providing
troduction to herbal medicine, with objectives anticipatory guidance about potential herb–
for the session outlined. Ten (10) clinical sce- drug interactions. The questions, explanations,
narios involving common herbal remedies and guidelines were printed as handouts.
were presented as board-examination–style Twelve (12) residents unable to attend confer-
multiple-choice questions, serving as tools for ence were given the pretest and tutorial text at
discussion. The tutorial addressed the same clinic and advised to study independently in
topics tested in the pretest but placed them in preparation for post-testing the next week.
the context of cases. The following are exam-
ples of scenarios:
Eighteen (18) internal medicine residents
were post-tested 1 week later (10 at conference
and 8 at clinic), with some lost to follow-up due
to scheduling. Post-tests included evaluation of
the tutorial.
The tutorial was scheduled as required con-
ferences in other departments as well. Pretests
were completed by all residents present: 7 in
preventive medicine, 12 in family medicine,
and 10 in obstetrics-gynecology. The text-only
intervention was not offered to these groups.
Surveys had been previously collected from 4
anesthesiology residents but the intervention
was limited to primary care specialties.
Seven (7) preventive medicine residents
completed post-tests 1 week later. Five (5) ob-
stetrics-gynecology residents completed them
2 weeks later. For logistical reasons, post-tests
in family medicine were distributed at the end
of the tutorial. Seven (7) residents completed
them but 5 had to leave to tend to patient care.
To assess utility of a Web-based intervention,
the pretest, tutorial, and post-test were placed
A 65-year-old man with benign prostatic
hyperplasia asks you whether there is an
alternative to conventional medical ther-
apy for his condition. His brother has sug-
gested that he try an herbal product.
Which of the following remedies was your
patient most likely recommended?
a) Cranberry
b)
Gingko biloba
c) Green tea leaf
d)
Ma huang
e) Saw palmetto
A 60-year-old man taking aspirin for a
history of stroke comes to your office for
a routine visit. His social history is posi-
tive for alcohol abuse. During your con-
versation he states that he has thought
about trying various herbal medicines to
enhance his health. Given his medical his-

574
MIKAIL ET AL.
online. All 87 medicine residents were assigned 17% second-year, 38% third-year, 9% fourth-
personal user ids/passwords and instructions on year, and 2% fifth-year residents.
using the Web site distributed in their mailboxes.
For residents in other departments (7 preventive
In scoring the knowledge
Knowledge score.
medicine, 21 family medicine, and 16 obstetrics- portion of the pretest, one point was given for
gynecology), chief residents announced the Web each correct answer on the multiple choice and
site and placed flyers in residents’ mailboxes true/false questions. One point was given for
about how to create user ids/passwords and each herbal remedy correctly matched to the
access the tutorial. Usage was tracked by the drug interaction presented. The knowledge
(WebCT program, WebCT, Inc., Lynnfield, MA). score equaled the achieved number of points
divided by the maximum number of points
possible.
The mean pretest knowledge score for the pi-
lot group was 30% ( 12, SD 9%). The
Statistical analysis
All data collected were entered into Excel
and analyzed using the SPSS program (SPSS,
Inc. Chicago, IL). Pretest and post-test knowl-
edge scores were compared by paired tests.
Subgroup analyses were performed using the
n 5
mean pretest knowledge score for all residents
was 32% ( 82, SD 11%). These scores did
5
n 5
5
t
not differ significantly by gender (
0.80),
p 5
postgraduate year level (
0.25), or depart-
p 5
independent samples test and one-way analy-
t
ment (
0.38).
p 5
sis of variance (ANOVA). Frequencies were
used to quantify degree of doctor–patient dia-
logue about herbal remedies (Likert scales), de-
sire for instruction (yes-no question), preferred
educational formats (checklist), and overall sat-
isfaction with the tutorial (Likert scale).
Table 1 depicts
Clinical and personal practices.
the prior clinical practices of all pretested resi-
dents.
. Ninety percent (90%) of
Desire for education
residents wanted to learn more about herbal
medicine. Of the instructional methods listed,
68% selected noon conference as a preferred
format, 33% online, 27% independent reading,
23% case-by-case with attending, and 12%
evening/weekend seminar.
RESULTS
Pretest
Including pilot study partici-
Demographics.
pants, 49 internal medicine residents, 12 fam-
ily medicine residents, 10 obstetrics-gynecol-
ogy residents, and 7 preventive medicine
residents, and 4 anesthesia residents completed
Post-test
Eighteen (18) internal medicine residents
pretests. Results were combined. Forty-six per- took post-tests (10 live tutorial, 8 text-only),
cent (46%) were male; 51% were female. Thirty- along with 7 preventive medicine, 7 family
three percent (33%) were first-year residents, medicine, and 5 obstetrics-gynecology resi-
TABLE 1. CLINICAL PRACTICES OF RESIDENTS PRETESTED
Clinical practices of
all residents
pretested ( 5 82)
n
Self-reported frequency of behavior
Behavior
Never or
almost never
30%
Sometimes
Almost always
or always
16%
Asked patients about herbal use
Recommended herbals
to their patients
Were asked about herbals
by their patients
48%
17%
77%
0%
40%
48%
6%

575
CASE-BASED TUTORIAL
dents (37 of 66 tutorial participants (a 56% re- will translate into changes in practice remains a
sponse rate). Mean post-test knowledge score question. Adjunct exercises might be introduced
was 61% (SD 12%), significantly higher than to encourage further study (e.g., asking partici-
5
their mean pretest score (34%, SD 13%) (
0.0001).
pants to collect their own set of “herbal medi-
cine cases” to use in future discussion).
5
p ,
In terms of the online tutorial, it was strik-
. The 7 family medicine res- ing that no residents logged on, because it was
Subgroup analysis
idents post-tested immediately after the tuto- the second most frequently preferred educa-
rial had significantly higher elevation in knowl- tional format selected on the pretest. One rea-
edge score (41%) than the remaining residents son could have been log-in difficulties. Time
(24%) (
0.022). The 24% elevation main- constraints might have played a role. The com-
p 5
tained significance (
0.0001).
puter exercise requires residents to find time to
p ,
The live lecture group (
29) increased its complete it. Alternatively, because most who
n 5
knowledge score from 32%–63% (
0.0001). completed the pretest participated in the live
p ,
The text-only group (
8) increased from or text-only versions, those who had chosen the
n 5
40%–55% (
p 5
provement was significantly smaller (
0.004). The text-only group’s im- online tutorial initially might not have felt the
0.041). need to access it. Given the initial interest ex-
pressed in it, the online version’s utility de-
p 5
. Twenty-five percent serves further exploration.
Subjective evaluation
(25%) of participants rated the tutorial excel-
The most substantial limitation of the study is
lent, 67% good, 8% fair, and 0% poor. They the relatively small sample size, especially with
praised the problem-based design, group dis- respect to stratified data. Response rate for post-
cussion, quality of handouts, and focus on tests (56%) was reduced because, as a result of
herb–drug interactions. Suggestions for im- scheduling, it was difficult to gather the same
provement included providing reference tables residents together at the same time for post-test
(subsequently added). Two (2) text-only par- administration, not because of self-selection. In
ticipants would have preferred live tutorial.
terms of subgroup analyses, the family practice
residents, post-tested immediately after the tu-
torial improved significantly more than the res-
idents tested later. But even when the family
practice results were factored out, score eleva-
tions remained statistically significant.
Computer intervention
WebCT showed no residents had accessed
the Web site.
Another limitation of the study is its general-
izability. As a suburban/rural medical center,
the hospitals’ patient population and overall dy-
DISCUSSION
PBL offered an attractive approach to teach- namic differs from urban hospitals, as might at-
ing the topic. The live tutorial increased knowl- titudes toward CAM education. Residents at ur-
edge significantly (mean post-test knowledge ban hospitals might prefer online tutorials they
score 61%), and participants praised its clin- can access independently if patient load prevents
5
ical correlation, group discussion, and empha- them from attending conferences regularly.
sis on herb–drug interactions.
Both small sample size and limited general-
The intervention’s success could be attributed izability can be addressed by replicating the
in part to the problem-based format, allowing study. Because the tutorial is relatively simple
residents to become keenly engaged in the sub- to implement, reproducing the investigation
ject, ask questions, and reinforce concepts seems feasible. Because the goal of the exercise
learned. It also might have helped that the tu- is not to train CAM practitioners but to intro-
torial was taught by a resident, enabling identi- duce residents to concepts of herbal medicine
fication with the group leader. The group for- important to medical practice, tutorial leaders
mat was flexible enough to allow participants to need not be herbalists. Chief residents could
tailor the exercise to their level of expertise. How conceivably administer it after brief study; the
to elevate scores beyond 61% and whether this handouts are self-explanatory.

576
As the prevalence of herbal remedy use grows,
equipping doctors with the vocabulary they need
to discuss the topic more authoritatively will al-
low them to offer patients proper precautions.
Considering that effective methods for integrat-
ing CAM into GME have yet to be fully explored,
the case-based approach appears promising, par-
ticularly with regard to herbal medicine.
MIKAIL ET AL.
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mainstream therapies for children: A curriculum eval-
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ACKNOWLEDGMENTS
Thanks to faculty at the State University of
New York at Stony Brook, School of Medicine
for their contributions: Michael Silverberg,
Ph.D. (for formatting online version of the tu-
torial); Fred Niegos, M.D. (for assisting in
scheduling conferences and distributing ques-
tionnaires); and to Dorothy Lane, M.D., M.P.H.,
and Catherine Messina, Ph.D. (for reviewing
survey design and analysis).
Miller LG, Murray WJ. Herbal Medicinals: A Clinician’s
Guide. New York: Haworth Press, 1998.
Ottariano SG. Medicinal Herbal Therapy: A Pharmacist’s
Viewpoint. Portsmouth, New Hampshire: Nicolin Fields
Publishing, 1999.
Address reprint requests to:
Claudia N. Mikail, M.D., M.P.H.
405 North Palm Drive #303
Beverly Hills, CA 90210
REFERENCES
Barzansky B, Jonas HS, Etzel S. Educational programs in
US medical schools: 1999–2000. JAMA 2000;284:1114–
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cmikail@pol.net
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